Amie Hornaman's Comprehensive Complete Health History Form

Thank you for choosing our office to assist you with your health care. Our ability to draw effective conclusions about your state of health and how to optimize its improvement depends largely on the accuracy of the information in which you provide, including symptoms that you may consider minor. Health issues may be influenced by many factors; therefore, it is important that you carefully consider the questions asked in this form as well as those posed by Amie Hornaman during your consultation. This will assist our goal to provide you with an optimal plan of health care, enhance our efficiency, and will provide effective use of your scheduled time.

PATIENT INFORMATION

Today's Date
*

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Month
-
Day Year

Name
*

First Name Last Name

E-mail
*

Address
*

Street Address

Street Address Line 2

City

State

Zip Code

Country

Home Phone Number
*

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Area Code Phone Number

Work Phone Number

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Area Code Phone Number

Cell Phone Number

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Area Code Phone Number

Preferred Contact

Phone Email Text

Birth Date
*

Month Day Year

Place of Birth

Gender

Male Female

Referred by:

Name of Primary Physician

First Name Last Name

Address of Primary Care Physician

Street Address

Street Address Line 2

City

State

Zip Code

Country

Phone Number of Primary Care Physician

-
Area Code Phone Number

Marital Status

Emergency Contact

First Name Last Name

Relationship with Emergency Contact

Address of Emergency Contact

Street Address

Street Address Line 2

City

State

Zip Code

Country

Occupation (Employer)

Average Hours Per Week

Retired?

No Yes

If No, Nature of business.

Genetic Background:

If Other, please list here:

Please Provide Us with Current and Ongoing Problems.

More Problems

What diagnosis or explanation(s), if any, have been given to you for these concerns?

When was the last time you felt well?

What seems to trigger your symptoms?

What seems to worsen your symptoms?

What seems to make you feel better?

What physician or other health care provider (including alternative or complimentary practitioners) have you seen for these conditions?

How much time have you lost from work or school in the past year due to these conditions?

Past Medical and Surgical History

If you have experienced reoccurrence of an illness, please indicate when or how often under comments.

Illnesses

More Illnesses

Injuries

More Injuries

Diagnostic Studies

More Diagnostic Studies

Surgeries

More Surgeries

Hospitalizations

How often have you taken antibiotics?

How often have you taken antibiotics? During Infancy/Childhood

How often have you taken antibiotics? As a Teen

How often have you taken antibiotics? As an Adult

How often have you taken oral steroids? (e.g. Prednisone, Cortisone, etc)

Infancy/Childhood

Teen

Adult

List all medications. Include all over-the-counter non-prescription drugs.

More Medications

List all vitamins, minerals, and any nutritional supplements that you are taking now.

More Vitamins

Are you allergic to any medication, vitamin, mineral, or other nutritional supplement?

No Yes

If Yes, please list:

Childhood History

Please anwser to the best of your knowledge.

Were You

Full Term Baby A Premature Birth ('preemie') Don't Know

Were You

Breast Fed Bottle Fed Don't Know

When pregnant with you, did your mother...?

Smoke Tobacco Use Recreational Drugs Drink Alcohol Use Estrogen Other Prescription or Non-Prescription Medications Not Sure

If unsure, but think there might be a possibility of any of the cases listed above, please explain why:

Immunization History

Please indicate if you have been vaccinated against any of the following diseases:

Have a high absence from school Experience chronic exposure to second hand smoke in your home Experience abuse Have alcoholic parents

If you had a high absence from school, why?

Female Medical History

(For Women Only)

Obstetrics History

Fill out a box, if yes, and provide number of occurrences.

Age of First Menses?

Frequency:

Length:

Painful?

Yes No

Clotting?

Yes No

Date of last menstrual period:

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Month
-
Day Year

Do you currently use contraception?

Yes No

If Yes, please indicate which form: Non-Hormonal

Condom Diaphragm IUD Partner Vasectomy

If Yes, please indicate which form: Hormonal

Birth Control Pills Patch Nuva Ring Other

Even if you are not currently using contraception, but have used hormonal birth control in the past, please indicate which type and for how long.

Do you experience breast tenderness, water retention, or irritability (PMS) symptoms in the second half of your cycle?

Yes No

Please advise of any other symptoms that you feel are significant:

Are you Menopausal?

Yes No

Do you currently take hormone replacement?

Yes No

If Yes, what type and for how long?

Date

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Month
-
Day Year

Diagnostic Testing

Date of Last PAP Test

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Month
-
Day Year

Normal Abnormal

Date of Last Mammogram

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Month
-
Day Year

Date of Last Breast Biopsy

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Month
-
Day Year

Date of Last Bone Density

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Month
-
Day Year

Family Health History

Please indicate current and past family history to the best of your knowledge. Please list ANY diseases/conditions that apply to family members including siblings, parents and grandparents. (i.e. cancer, heart conditions, depression, thyroid conditions…)

More Family Members / Deseases

Review of Symptoms

Check those items that applied to you in the past and those that you are currently experiencing.

General

Review of Symptoms Check those items that applied to you in the past and those that you are currently experiencing.

Occur in the Morning Occur in the Afternoon Occur in the Evening Occur in the Evening Generally Severe Typically as a Result of Migraines Affect the Frontal Region Affect the Occipital Region Relieved by Eating Sweets

Pain Wakes You Weakness in Legs and Arms Balance Problems Muscle Cramping Head Injury Muscle Stiffness in the Morning Damp Weather Bothers You

For Both Women & Men

Emotional:

Frustration Frequently Keyed Up and Jittery Startled by Sudden Noises Anxiety/Feeling of Panic Go to Pieces Easily Forgetful Listless/Groggy Withdrawn Feeling/Feeling "Lost" Had Nervous Breakdown(s) Unable to Concentrate/Short Attention Span Vision Changes Unable to Reason Considered a Nervous Person by Others Tends to Worry Needlessly Unusual Tension Emotional Numbness Often Break Out in Cold Sweats Profuse Sweating Depressed Previously Admitted for Psychiatric Care Often Awakened by Frightening Dreams Family Member has had Nervous Breakdown(s) Use Tranquilizers Misunderstood by Others Irritable Feeling of Hostility/Volatile or Aggressive Fatigue Hyperactive Restless Leg Syndrome Considered Clumsy Unable to Coordinate Muscles Have Difficulty Falling Asleep Have Difficulty Staying Asleep Daytime Sleepiness Am a Workaholic Have had Hallucinations Have Considered Suicide Have Overused Alcohol Family History of Alcohol Abuse Cry Often Feel Insecure Have Overused Drugs Addicted or Have Been Addicted to Drugs Extremely Shy

Pain Assessment

Are you Currently in Pain

Yes No

If Yes, Is the source of your pain due to an injury

Yes No

If pain is due to injury, please describe your injury and the date in which it occurred:

If Not due to injury, please describe how long you have experienced this pain and what you believe it is attributed to:

Social History

Because stress has a direct effect on your overall health and wellbeing that often leads to illness, immune system dysfunction, and emotional disorders, it is important that your practitioner is aware of any stressful influences that may be impacting your health. Informing your doctor allows him/her to offer you supportive treatment options and optimize the outcome of your health care.

Stress/Psychosocial History

Are you happy overall?

Yes No

Do you feel you can easily handle the stress in your life?

Yes No

If No, do you believe that stress is presently reducing the quality of your life?

Yes No

If yes, do you believe that you know the source of your stress?

Yes No

If that is the case, what do you believe it to be?

How well have things been going for you?

At school:

Very Well Fine Poorly Very Poorly Does not Apply

In Your Job:

Very Well Fine Poorly Very Poorly Does not Apply

In Your Social Life:

Very Well Fine Poorly Very Poorly Does not Apply

With Your Close Friends:

Very Well Fine Poorly Very Poorly Does not Apply

With Sex:

Very Well Fine Poorly Very Poorly Does not Apply

With Your Attitude:

Very Well Fine Poorly Very Poorly Does not Apply

With Significant Other:

Very Well Fine Poorly Very Poorly Does not Apply

With Your Children:

Very Well Fine Poorly Very Poorly Does not Apply

With Your Parents:

Very Well Fine Poorly Very Poorly Does not Apply

Which of the following provide you with emotional support?

Spouse Family Friends Religious/Spiritual Pets

If there are others that provide you with emotional support, but are not already mentioned, please list them below:

List your Hobbies and Leisure Activities:

Is there anything that you would like to discuss with your functional medicine practitioner today that you feel you cannot indicate here?

Yes No

Rediness Assessment

In order to improve your health, how willing are your to:Rate on a scale of 5 (very willing), to 1 (not willing)

Significantly modify your diet

1

2

3

4

5

Worst

Best

Take nutritional supplements each day

1

2

3

4

5

Worst

Best

Keep a record of everything you eat each day

1

2

3

4

5

Worst

Best

Engage in regular exercise

1

2

3

4

5

Worst

Best

Modify your lifestyle (ie. work demands, sleep habits)

1

2

3

4

5

Worst

Best

Have periodic lab tests to assess progress

1

2

3

4

5

Worst

Best

Practice relaxation techniques

1

2

3

4

5

Worst

Best

Do you have any remaining comments that were not addressed in this form?

Thank you for taking the time to complete this health history medical questionnaire. The information derived from all of these forms will provide invaluable data in identifying the underlying problems of your health concerns rather than simply treating the symptoms alone.

We look forward to helping you achieve lifelong health and well being.